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Based on policy and procedure review, closed medical record review, and staff interview the hospital's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of Patients' Rights to ensure care in a safe setting and failed to have an organized Nursing Service to meet the patient care needs.

The findings include:

1. The facility's staff failed to provide care in a safe setting to ensure an effective communication system and adequate staffing were available to care for telemetry monitored patients. Therefore, facility staff failed to detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient #7)

~cross refer to 482.13 Patient Rights Condition: Tag A0115

2. The hospital's nursing staff failed to have an effective nursing service providing oversight to ensure registered nursing staff supervised and evaluated patient care.

~cross refer to 482.23 Nursing Condition: Tag A0385

3. The hospital's "Patient Safety and Clinical Quality Committee Meeting Minutes" review and staff interview, the hospital failed to implement program activities for it's patient telemetry monitoring staff communication and staff call bell responses reported as problem-prone areas with an impact on patient safety and quality of care.

~Cross refer to 482.21 (b)(2)(ii), (c)(1), (c)(3) Quality Assessment Performance Improvement, Standard Tag A0283

Based on policy and procedure review, medical record review, telemetry log review and staff interview the facility's staff failed to provide care in a safe setting to ensure an effective communication system and adequate staffing were available to care for telemetry monitored patients. Therefore, facility staff failed to detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient # 7).

The findings include:

1. The facility's staff failed to provide care in a safe setting to ensure an effective communication system and adequate staffing available to care for telemetry monitored patients. Therefore, facility staff failed to detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient # 7)

~cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144


2. The facility's nursing staff failed supervise and evaluate patient care by failing to communitcate, and respond in a manner to assess and detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient #7).

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

Based on policy and procedure review, medical record review, telemetry log review and staff interview the facility's staff failed to provide care in a safe setting to ensure an effective communication system and adequate staffing were available to care for telemetry monitored patients. Therefore, facility staff failed to detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient # 7).

The findings include:

Review of hospital policy "Title/Description: Telemetry Monitoring on the Medical/Surgical Units: R/R 01/12" revealed "PURPOSE: To provide guidelines for safe and effective telemetry monitoring of patients RESPONSIBLE PERSON: RN/LPN POLICY: 1. The physician (and/or designee) must order continuous cardiac monitoring via telemetry on the Medical or Surgical Unit 2. EKG change will be monitored in an ongoing manner by qualified personnel. 3. EKG strips will be interpreted by qualified personnel and verified by licensed staff RESPONSIBILITY OF TELEMETRY TECH OR NURSE AT MONITORING STATION: *Continually assess EKG pattern * Obtain two rhythm strips q (every) shift or more frequently if indicated, placing one (1) strip in Charge Nurse's telemetry log book and posting the second strip on the patient's medical record. *Maintain alarms on at all times *Notify Medical or Surgical Unit Charge Nurse and physician of patient with suspected rhythm and conduction disturbances as indicated *Initiate code blue for life threatening dysrhythmias EQUIPMENT: 1. Central Monitor...5. Telemetry log Book

Closed medical record review of Patient #7 revealed a 60 year old male who was admitted through the facility's emergency department on 06/20/2016. Review of history and physical revealed "Date of Admission: 06/20/2016; Chief Complaint: Abdominal pain of one-day duration; History of present illness: ...is a 60 year old gentleman with a past medical history symptom for hypertension, hyperlipidemia, diabetes, CVA (stroke), ESRD (end stage renal disease) on dialysis... Had been having abdominal pain for 2 days of which he was sent to the emergency room for evaluation. In the emergency room, he was seen evaluated, clinical exam was significant for abdominal distention, CT scan of the abdomen which showed massive fecal impaction of colon. Initial effort at disimpaction was unsuccessful, also GoLYTELY (bowel cleansing solution) was used but with very little results. He was admitted for further management..." Record review of ED (emergency department) Nursing Flowsheet revealed vital signs at 1255 on 06/20/2016 temperature 97.9, HR102, resp 20, BP 116/93 and SpO2 (oxygenation) 96%. and the patient was transported to the inpatient unit at 1313. Record review revealed at 1623 "Observations: Lying in bed; No signs of distress; Head of Bed Greater/Equal to 30 Degrees; LOC ( level of consciousness) Alert; Level of Awareness: Oriented to person; Pain: Reassessment; Denies Pain." Record review revealed at 1800 entered at 2013 "Observations: Lying in bed; MD notified regarding : pt vital signs and condition new order received for telem...LOC: Alert; Lethargic; Respirations: Regular; Shallow; Pain: Group Note: no expression of discomfort noted." Record review of Physician orders revealed at 1920 " Telephone Order description: Telemetry Acknowledgement at 2129 (2 hours 9 minutes later)." Record review revealed no telemetry monitor strips available for review. Record review of vital signs at 2015 revealed BP: 146/117, Pulse 105, Temp: 95.2 F, Resp: 20 and O2 (oxygen) sat: 94% (Room air). Record review revealed at 2131 "Observations: Lying in bed; Respirations,easy, unlabored and regular; No signs of Distress Observed... Rounds Note: pt nonverbal but alert responded to name being called and looked at nurse moved his head towards nurse and shook his head in response to questions..." Record review at 2315 entered on 0243 revealed "Observations: Lying in bed; Rounds Note: enema given to patient and repositioned to head of bed x 2 person assistance... Category Note: RT called to place patient on mask due to labored breathing..." Record review at 0248 "Category Note: called by telemetry tech that patient was asystole on the telemetry monitor pt found in room unresponsive no pulse not breathing nurse by herself so she called for a code to be called and started chest compressions at 2339 code team arrived at 2342 [sic]." Record review of "Code Blue Sheet" revealed "Date: June 20, 2016; Time Code Announced: 2342; Time CPR started: 2342; Time MD arrived: 2345; Time Code Completed: 2400... Outcome; Resuscitated? :No..."

Review of the "Telemetry Log" which began 06/21/16-08/09/16 revealed:
"Date: 07/03/16 Time: 0017 Room: ME46 Nurse: No one Answered/ Charge # Comment: Off Tele
Date: 07/04/16 Time: 2305 Room: ME 60 Nurse: (name) Comment: leads off
Date: 07/04/16 Time: 2315 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/04/16 Time: 2335 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/05/16 Time: 0025 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/05/16 Time: 0055 Room: ME 60 Nurse (name) Comment: leads off still (put back on at 0100 with (name) called ( 1 hour 55 minutes off telemetry monitoring)
Date: 07/10/16 Time: 2022 Room: M61 & M54 Nurse: No answer Comment: Off Monitor
Date: 07/10/16 Time: 2024 Room: M46,M61&M54 Nurse: No answer Comment: Off Monitor
Date: 07/10/16 Time: 2035 Room: M46 Nurse: No name Comment: Off Monitor
Date: 07/10/16 Time: 2054 Room: M46 Nurse: No answer Comment: Off Monitor
Date: 07/13/16 Time: 2136 Room: M 59 Nurse: (name) Comment: Off tele- on 2230 (54 minutes off telemetry monitoring)
Date: 07/22/16 Time: 0520 Room: MS51 Nurse: (name) Comment: told RN LL off
Date: 07/22/16 Time: 0550 Room: MS51 Nurse: RN Comment: Can't find RN, phones busy will check
Date: 07/22/16 Time: 0610 Room: MS51 Nurse: RN Comment: RN phone dead Can't find (name)
Date: 07/22/16 Time: 0630 Room: MS51 Nurse: RN Comment: STILL CAN'T FIND RN (NAME) (told charge)
Date: 07/22/16 Time: 0657 Room: MS51 Nurse: (name) Comment: (name) will go check pt still off ( 1 hour 37 minutes of telemetry monitoring)
Date: 08/9/16 Time: 0016 Room: 45 Nurse: (name) Comment: Off tele LL off
Date: 08/9/16 Time: 0035 Room: 45 Nurse: (name) Comment: Off tele still
Date: 08/9/16 Time: 0050 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0115 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0130 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0140 Room: 45 Nurse: (name) Comment: RN said he was told to leave him alone because he was getting up, and it would be at least 30 more minutes because he had to pass meds. I called sup to go put pt on. pt back on at 0145 (1 hour 29 minutes off telemetry monitoring )"

No dates of log book prior to 06/21/2016 available for review.

Telephone interview on 8/10/2016 at 0930 with RN #1 revealed she remembered the events of 06/20/2016 and Patient #7. Interview revealed she had given the enema and walked out of the patient's room. Interview revealed she was walking out of the medication room when the telemetry tech was walking down and approached her to check on Patient #7. Interview revealed the Telemetry tech stated there was no answer when she tried called the phones and the patient appears to be in asystole. Interview revealed when she walked back into the patient's room the patient was pulseless and she began chest compressions and called a Code Blue. Interview revealed process for telemetry set up once a patient is placed on the monitor is to call the telemetry tech and verify the rhythm. Interview revealed once verified a strip with be printed and placed on the patient chart and repeated once per shift.

Telephone interview with Telemetry Tech on 08/10/2016 at 0945 revealed if a patient's telemetry alarms she calls the nurse and there is no answer she calls the charge nurse. Interview revealed if there is no response from nursing her practice is to go check the patient herself. Interview revealed there has been delays in response times on medical side versus progressive care side. Interview revealed she does not remember the events of 06/20/2016 but its not uncommon for her to go check on a patient. Interview revealed a nurse will call once a new patient is placed on telemetry to confirm monitoring is capturing and 2 strips will be printed; one placed on the patient chart and one placed on a telemetry log which gets shreaded daily. Interview revealed monitoring strips are printed every shift and more often depending on the changes in condition.

Interview on 08/10/2016 at 1205 with Nursing Serivces Director revealed there are no hardwired montiors in the patient care rooms on the medical/surgical floor. Interview revealed telemetry monitoring is done remotely at a central station. Interview revealed when an alarm needs attention the telemetry tech notifies the nurse by phone and if the nurse does not annswer the tech notify's the charge nurse. Interview revealed the staffing ratio on the medical floor is 7 patients to 1 Nurse. Interview revealed the Charge Nurse has a full patient assignment in addition to Charge Nurse duties. Interview revealed if nurse or charge nurse are not available the tech then notify's the supervisor and/or finds someone qualified to sit at the central station and can go check the patient. Interivew revealed only alarms that can be heard related to telemetry are at the central station. Interview confirmed a nurse relies on notification by phone call or in person that a patient's telemetry alarm is activated.

In summary, the nursing staff failed to respond to telephone calls from monitoring technicians on notifications of patient cardiac monitor alarms and changes in patient cardiac rhythms which resulted in delays in medical intervention.

Based on policy and procedure review, the hospital's "Telemetry Log" review, patient interview, the hospital's "Patient Safety and Clinical Quality Committee Meeting Minutes" review and staff interview, the hospital QAPI staff failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program for implementing and focusing on patient telemetry monitoring staff communication and staff call bell responses reported as problem-prone areas with an impact on patient safety and quality of care.

The findings include:

A) The hospital staff failed to implement and monitor patient telemetry monitoring staff communication and staff call bell responses reported as problem-prone areas with an impact on patient safety and quality of care.

~Cross refer to 482.21 (b)(2)(ii), (c)(1), (c)(3) Quality Assessment Performance Improvement, Standard Tag A0283

B) The hospital's staff failed to provide care in a safe setting to ensure an effective communication system and adequate staffing available to care for telemetry monitored patients. Therefore, facility staff failed to detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient #7)

~Cross refer to 482.13 (c)(2) Patient Rights, Standard Tag A0144

Based on policy and procedure review, the hospital's "Telemetry Log" review, patient interview, the hospital's "Patient Safety and Clinical Quality Committee Meeting Minutes" review and staff interview, the hospital failed to implement program activities for it's patient telemetry monitoring staff communication and staff call bell responses reported as problem-prone areas with an impact on patient safety and quality of care.

The findings include:

Review of the hospital's policy and procedure "2016 Performance Improvement Plan-Patient Safety & Clinical Quality", last revised 06/2016, revealed "I. Procedure: The Performance Improvement Plan for Patient Safety and Clinical Quality (PI Plan) outlines the systematic organizational process of creating and supporting a culture of quality and safety that promotes a proactive, interdisciplinary approach to reducing the risk of harm and optimizing quality outcomes. The plan is used as a guide to develop, design, measure, assess and improve systems, processes, and the environment of care. Care, service and quality are systematically assessed throughout the organization by means of monitoring the performance of systems, processes, and clinical outcomes." Further review of the policy revealed "II. Leadership Accountability and Responsibility: The Advisory Board of _____(Hospital Name) has the overall responsibility for the safety and quality of the care, treatment, and services provided by all providers and employees. Senior leadership, elected officers of the organized Medical Staff and ___(Hospital Name) departmental directors share in the Advisory Board's primary responsibility for the provision of safe quality care and services. Senior leadership is responsible for:

~identification of safety and quality priorities
~all performance improvement activities
~reported safety and quality issues
~proposed solutions and their impact on hospital resources
~safety and quality issues specific to the population served.

D. Departmental Specific Performance/Ongoing Performance Improvement: Departmental specific measures are identified, monitored and evaluated to determine performance, outcome and other activities which can help the hospital improve its ability to provide quality care, treatment and services. These departments report quarterly to the Patient Safety and Clinical Quality Committee. Ongoing monitors reflect high-risk, high volume, problem-prone processes as identified through data collection and compliance wit standards of care. Each department director is responsible for identifying and reporting their opportunities for improvement."

Review of the "Telemetry Log" dated 06/21/2016 - 08/09/2016 for staff communication related to problems detected in telemetry monitoring revealed as follows:

"Date: 07/03/16 Time: 0017 Room: ME46 Nurse: No one Answered/ Charge # Comment: Off Tele
Date: 07/04/16 Time: 2305 Room: ME 60 Nurse: (name) Comment: leads off
Date: 07/04/16 Time: 2315 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/04/16 Time: 2335 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/05/16 Time: 0025 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/05/16 Time: 0055 Room: ME 60 Nurse (name) Comment: leads off still (put back on at 0100 with (name) called ( 1 hour 55 minutes off telemetry monitoring)
Date: 07/10/16 Time: 2022 Room: M61 & M54 Nurse: No answer Comment: Off Monitor
Date: 07/10/16 Time: 2024 Room: M46,M61&M54 Nurse: No answer Comment: Off Monitor
Date: 07/10/16 Time: 2035 Room: M46 Nurse: No name Comment: Off Monitor
Date: 07/10/16 Time: 2054 Room: M46 Nurse: No answer Comment: Off Monitor
Date: 07/13/16 Time: 2136 Room: M 59 Nurse: (name) Comment: Off tele- on 2230 (54 minutes off telemetry monitoring)
Date: 07/22/16 Time: 0520 Room: MS51 Nurse: (name) Comment: told RN LL off
Date: 07/22/16 Time: 0550 Room: MS51 Nurse: RN Comment: Can't find RN, phones busy will check
Date: 07/22/16 Time: 0610 Room: MS51 Nurse: RN Comment: RN phone dead Can't find (name)
Date: 07/22/16 Time: 0630 Room: MS51 Nurse: RN Comment: STILL CAN'T FIND RN (NAME) (told charge)
Date: 07/22/16 Time: 0657 Room: MS51 Nurse: (name) Comment: (name) will go check pt still off ( 1 hour 37 minutes of telemetry monitoring)
Date: 08/9/16 Time: 0016 Room: 45 Nurse: (name) Comment: Off tele LL off
Date: 08/9/16 Time: 0035 Room: 45 Nurse: (name) Comment: Off tele still
Date: 08/9/16 Time: 0050 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0115 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0130 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0140 Room: 45 Nurse: (name) Comment: RN said he was told to leave him alone because he was getting up, and it would be at least 30 more minutes because he had to pass meds. I called sup to go put pt on. pt back on at 0145 (1 hour 29 minutes off telemetry monitoring )"

No dates of log book prior to 06/21/2016 available for review.

Interview on 08/09/2016 at 1131 with patient #11 during tour and observation on the hospital's "Progressive Care Unit" revealed "When I was here before (month prior) on the medical floor, I caught the staff out at the nurse's station playing on their phones when they would not answer the call bells. I talked to management but they did not stop them." The interview revealed he was happy with his care but did not like the slow call bell response.

Interview on 08/10/2016 at 1008 with patient #9 during tour and observation on the hospital's "Medical Unit" revealed "The call bells takes sometimes longer than 30 minutes to answer." The interview revealed the nursing unit staff would sometimes take way too long to follow up when he would call out on his call bell.

Interview on 08/10/2016 at 1040 with patient #10 during tour and observation on the hospital's "Medical Unit" revealed that over all her care was good but that she was here before and had to have her husband stay with her due to staff taking over an hour or so to respond to her room.

Interview on 08/10/2016 at 1050 with the hospital's RN (Registered Nurse) #2 revealed she has heard multiple complaints from different patients about staff on the midnight shift not responding to call bells appropriately. The interview revealed the hospital's management was aware of the patient's concerns.

Interview on 08/10/2016 at 1110 with the hospital's RN #3 revealed she was a nurse at the hospital since the last 11 months. The interview also revealed that she has also heard complaints from the patients related to their call bells not being answered or responded to in a timely fashion. The interview also revealed that when she receives a complaint from a patient or family that she tells her charge nurse.

Review of the hospital's "Patient Safety and Clinical Quality Committee Meeting Minutes" for 2016 revealed there was no QAPI (Quality Assessment Performance Improvement) implemented program activities or monitoring for patient telemetry monitoring or call bell responses by staff for patients. The documentation review revealed no evidence that the areas of concerns in staff response to telemetry monitoring problems or patient reported lack of an appropriate call bell response was found.

Interview on 08/10/2016 at 1420 with the hospital's QAPI responsible person (Executive Director-Quality Management/Risk Management) revealed that since her role starting 12/2015 there was not been any telemetry monitoring or call bell response monitoring by the QAPI team. The interview revealed that complaints were known about call bell responses from the staff but no specific action or monitoring has been done at the present time from QAPI.

In summary, the hospital started a telemetry log for staff communication of telemetry problems in June 2016. Problems of communication were documented related to lack of telemetry monitoring and/or intervention, the hospital's QAPI team failed to monitor the processes. The call bell responses reported as problems to the hospital's management from patients and staff members and failed to be assessed and monitored by the QAPI team.

Based on policy and procedure review, medical record review, telemetry log review and staff interview the facility's nursing staff failed supervise and evaluate patient care by failing to communicate, and respond in a manner to assess and detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient #7). The cumulative effect of this systemic problem resulted in the facility's inability to ensure that facility staff were able to effectively communicate and respond in a manner to assess and detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention for each of the potential 48 telemetry monitored at the facility resulting in an identification of Immediate Jeopardy.

The findings include:

The facility's nursing staff failed supervise and evaluate patient care by failing to communitcate, and respond in a manner to assess and detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient #7).

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

Based on policy and procedure review, medical record review, telemetry log review and staff interview the facility's nursing staff failed supervise and evaluate patient care by failing to communitcate, and respond in a manner to assess and detect significant and life-threatening variations in a telemetry monitored patient's cardiac rhythm to facilitate early therapeutic intervention in 1 of 4 telemetry monitored patients (Patient # 7).

The findings include:

Review of hospital policy "Title/Description: Telemetry Monitoring on the Medical/Surgical Units: R/R 01/12" revealed "PURPOSE: To provide guidelines for safe and effective telemetry monitoring of patients RESPONSIBLE PERSON: RN/LPN POLICY: 1. The physician (and/or designee) must order continuous cardiac monitoring via telemetry on the Medical or Surgical Unit 2. EKG change will be monitored in an ongoing manner by qualified personnel. 3. EKG strips will be interpreted by qualified personnel and verified by licensed staff RESPONSIBILITY OF TELEMETRY TECH OR NURSE AT MONITORING STATION: *Continually assess EKG pattern * Obtain two rhythm strips q (every) shift or more frequently if indicated, placing one (1) strip in Charge Nurse's telemetry log book and posting the second strip on the patient's medical record. *Maintain alarms on at all times *Notify Medical or Surgical Unit Charge Nurse and physician of patient with suspected rhythm and conduction disturbances as indicated *Initiate code blue for life threatening dysrhythmias EQUIPMENT: 1. Central Monitor...5. Telemetry log Book

Closed medical record review of Patient #7 revealed a 60 year old male who was admitted through the facility's emergency department on 06/20/2016. Review of history and physical revealed " Date of Admission: 06/20/2016; Chief Complaint: Abdominal pain of one-day duration; History of present illness: ...is a 60 year old gentleman with a past medical history symptom for hypertension, hyperlipidemia, diabetes, CVA (stroke), ESRD (end stage renal disease) on dialysis... Had been having abdominal pain for 2 days of which he was sent to the emergency room for evaluation. In the emergency room, he was seen evaluated, clinical exam was significant for abdominal distention, CT scan of the abdomen which showed massive fecal impaction of colon. Initial effort at disimpaction was unsuccessful, also GoLYTELY (bowel cleansing solution) was used but with very little results. He was admitted for further management..." Record review of ED (emergency department) Nursing Flowsheet revealed vital signs at 1255 on 06/20/2016 temperature 97.9, HR102, resp 20, BP 116/93 and SpO2 (oxygenation) 96%. and the patient was transported to the inpatient unit at 1313. Record review revealed at 1623 "Observations: Lying in bed; No signs of distress; Head of Bed Greater/Equal to 30 Degrees; LOC ( level of consciousness) Alert; Level of Awareness: Oriented to person; Pain: Reassessment; Denies Pain." Record review revealed at 1800 entered at 2013 "Observations: Lying in bed; MD notified regarding : pt vital signs and condition new order received for telem...LOC: Alert; Lethargic; Respirations: Regular; Shallow; Pain: Group Note: no expression of discomfort noted." Record review of Physician orders revealed at 1920 " Telephone Order description: Telemetry Acknowledgement at 2129 (2 hours 9 minutes later)." Record review revealed no telemetry monitor strips available for review. Record review of vital signs at 2015 revealed BP: 146/117, Pulse 105, Temp: 95.2 F, Resp: 20 and O2 (oxygen) sat: 94% (Room air). Record review revealed at 2131 "Observations: Lying in bed; Respirations,easy, unlabored and regular; No signs of Distress Observed... Rounds Note: pt nonverbal but alert responded to name being called and looked at nurse moved his head towards nurse and shook his head in response to questions..." Record review at 2315 entered on 0243 revealed "Observations: Lying in bed; Rounds Note: enema given to patient and repositioned to head of bed x 2 person assistance... Category Note: RT called to place patient on mask due to labored breathing..." Record review at 0248 "Category Note: called by telemetry tech that patient was asystole on the telemetry monitor pt found in room unresponsive no pulse not breathing nurse by herself so she called for a code to be called and started chest compressions at 2339 code team arrived at 2342 [sic]." Record review of "Code Blue Sheet" revealed "Date: June 20, 2016; Time Code Announced: 2342; Time CPR started: 2342; Time MD arrived: 2345; Time Code Completed: 2400... Outcome; Resuscitated? :No..."

Review of the "Telemetry Log" which began 06/21/16-08/09/16 revealed:
"Date: 07/03/16 Time: 0017 Room: ME46 Nurse: No one Answered/ Charge # Comment: Off Tele
Date: 07/04/16 Time: 2305 Room: ME 60 Nurse: (name) Comment: leads off
Date: 07/04/16 Time: 2315 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/04/16 Time: 2335 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/05/16 Time: 0025 Room: ME 60 Nurse (name) Comment: leads off still
Date: 07/05/16 Time: 0055 Room: ME 60 Nurse (name) Comment: leads off still (put back on at 0100 with (name) called ( 1 hour 55 minutes off telemetry monitoring)
Date: 07/10/16 Time: 2022 Room: M61 & M54 Nurse: No answer Comment: Off Monitor
Date: 07/10/16 Time: 2024 Room: M46,M61&M54 Nurse: No answer Comment: Off Monitor
Date: 07/10/16 Time: 2035 Room: M46 Nurse: No name Comment: Off Monitor
Date: 07/10/16 Time: 2054 Room: M46 Nurse: No answer Comment: Off Monitor
Date: 07/13/16 Time: 2136 Room: M 59 Nurse: (name) Comment: Off tele- on 2230 (54 minutes off telemetry monitoring)
Date: 07/22/16 Time: 0520 Room: MS51 Nurse: (name) Comment: told RN LL off
Date: 07/22/16 Time: 0550 Room: MS51 Nurse: RN Comment: Can't find RN, phones busy will check
Date: 07/22/16 Time: 0610 Room: MS51 Nurse: RN Comment: RN phone dead Can't find (name)
Date: 07/22/16 Time: 0630 Room: MS51 Nurse: RN Comment: STILL CAN'T FIND RN (NAME) (told charge)
Date: 07/22/16 Time: 0657 Room: MS51 Nurse: (name) Comment: (name) will go check pt still off ( 1 hour 37 minutes of telemetry monitoring)
Date: 08/9/16 Time: 0016 Room: 45 Nurse: (name) Comment: Off tele LL off
Date: 08/9/16 Time: 0035 Room: 45 Nurse: (name) Comment: Off tele still
Date: 08/9/16 Time: 0050 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0115 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0130 Room: 45 Nurse: (name) Comment: Still off tele
Date: 08/9/16 Time: 0140 Room: 45 Nurse: (name) Comment: RN said he was told to leave him alone because he was getting up, and it would be at least 30 more minutes because he had to pass meds. I called sup to go put pt on. pt back on at 0145 (1 hour 29 minutes off telemetry monitoring )"

No dates of log book prior to 06/21/2016 available for review.

Telephone interview on 8/10/2016 at 0930 with RN #1 revealed she remembered the events of 06/20/2016 and Patient #7. Interview revealed she had given the enema and walked out of the patient's room. Interview revealed she was walking out of the medication room when the telemetry tech was walking down and approached her to check on Patient #7. Interview revealed the Telemetry tech stated there was no answer when she tried called the phones and the patient appears to be in asystole. Interview revealed when she walked back into the patient's room the patient was pulseless and she began chest compressions and called a Code Blue. Interview revealed process for telemetry set up once a patient is placed on the monitor is to call the telemetry tech and verify the rhythm. Interview revealed once verified a strip with be printed and placed on the patient chart and repeated once per shift.

Telephone interview with Telemetry Tech on 08/10/2016 at 0945 revealed if a patient's telemetry alarms she calls the nurse and there is no answer she calls the charge nurse. Interview revealed if there is no response from nursing her practice is to go check the patient herself. Interview revealed there has been delays in response times on medical side versus progressive care side. Interview revealed she does not remember the events of 06/20/2016 but its not uncommon for her to go check on a patient. Interview revealed a nurse will call once a new patient is placed on telemetry to confirm monitoring is capturing and 2 strips will be printed; one placed on the patient chart and one placed on a telemetry log which gets shreaded daily. Interview revealed monitoring strips are printed every shift and more often depending on the changes in condition.

Interview on 08/10/2016 at 1205 with Nursing Serivces Director revealed there are no hardwired montiors in the patient care rooms on the medical/surgical floor. Interview revealed telemetry monitoring is done remotely at a central station. Interview revealed when an alarm needs attention the telemetry tech notifies the nurse by phone and if the nurse does not annswer the tech notify's the charge nurse. Interview revealed the staffing ratio on the medical floor is 7 patients to 1 Nurse. Interview revealed the Charge Nurse has a full patient assignment in addition to Charge Nurse duties. Interview revealed if nurse or charge nurse are not available the tech then notify's the supervisor and/or finds someone qualified to sit at the central station and can go check the patient. Interivew revealed only alarms that can be heard related to telemetry are at the central station. Interview confirmed a nurse relies on notification by phone call or in person that a patient's telemetry alarm is activated.

In summary, the nursing staff failed to respond to telephone calls from monitoring technicians on notifications of patient cardiac monitor alarms and changes in patient cardiac rhythms which resulted in delays in medical intervention.

Based on policy and procedure review, medical record review, and staff interview, the hospital's nursing staff failed to verify that blood product transfusion information was correct in 1 of 3 sampled patient records of patient's receiving blood product transfusions (Patient #1).

The findings include:

Review of the facility's policy and procedure "Blood Product Administration-Routine Administration of, PC-8" (Approved 09/2015) revealed "Infusing Blood Products: Verifying and monitoring of blood product transfusions (except Albumin) must be documented on the Blood Bank/Transfusion Report Form. 3. Both nurses sign the "Transfusion Record" section of the Blood Bank/Transfusion Report verifying that the information is correct."

Closed medical record review for patient #1 revealed the patient was a 69 year-old that received blood product transfusions at the hospital on 07/06/2016. Review of the medical record revealed physician orders dated 07/05/2016 at 1730 by physician #1 for "Packed RBCs (Red Blood Cells), Leukoreduced, 2 Units, once routine." The "Blood Bank/Transfusion Report Form" completed for the patient dated 07/06/2016 revealed the patient had the blood product administration started at 1455 and infused through 1708. Further review of the form "Blood Bank/Transfusion Report Form" revealed only one RN (Registered Nurse-Not legible Name) signed the form as recipient ID (identification) confirmed by (Nurse/MD (Medical Doctor) with the section of the form for "Transfusionist (Nurse/MD) left blank and not authenticated. The review of the form further revealed the section of the form for "Date/Time Stopped" was also left blank and not completed. The review revealed the hospital's nursing staff failed to verify that blood product transfusion information was correct for patient #1 by both nursing staff members failing to sign the "Transfusion Record" section of the Blood Bank/Transfusion Report verifying that the information is correct.

Interview on 08/09/2016 at 1535 with the hospital's Chief Nursing Officer revealed the nursing staff should sign the "Transfusion Record" section of the Blood Bank/Transfusion Report verifying that the information is correct. The interview confirmed the medical record finding.

Based on policy and procedure review, observation and staff interview, the hospital's infection control officer failed to ensure infection prevention guidelines were implemented by the hospital's nursing staff by failing perform hand hygiene during glove changes in 1 of 1 observed nursing staff administering a blood product (RN #4, Patient #8) and failing to prevent use of a cooling fan in a patient care area.

The findings include:

Review of the hospital's policy and procedure "Infection Prevention Guidelines, IC-113", Last revised 02/2016, revealed "Hand Hygiene is the single most important factor in preventing the spread of infection. Standard precautions must be adhered to by employees with direct patient care. Fans used during patient care are considered one time use and should be discarded or sent home with patient at discharge."

1. Observation on 08/10/2016 at 0942 in the hospital's oncology outpatient unit revealed RN #4 administered blood products to patient #8. The observation at 0944 revealed the nurse hung the blood and handled the blood bag and blood lines filled with blood while wearing disposable gloves. Continued observation revealed the RN removed the gloves and without hand hygiene, wiped her nose and began to document in the hospital's automated computer station. The RN was observed to wash her hands at 0951 in a hand washing sink after going from dirty contaminated blood lines to documenting a computer terminal used by multiple staff.

Interview on 08/10/2016 at 0956 with the unit's Director during the observation revealed the staff should perform hand hygiene after removing gloves and before touching shared equipment. The interview confirmed the finding.

2. Observation on 08/10/2016 at 0941 in the hospital's oncology outpatient unit revealed RN #4 administered blood products to patient #8. Further observation revealed that a cooling fan was placed on top of the nursing station counter and was turned on and positioned where it was blowing air towards RN #4 and patient #8 who was noted to have blood being administered through a port-a-cath site. The observation revealed potential cross-contamination from the fan blowing air around the unit and towards the patient.

Interview on 08/10/2016 at 0956 with the unit's Director during the observation revealed the staff should not have a fan inside of the patient treatment area that could cross-contaminate. The interview confirmed the finding.

NC00118815